ATION FEI
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s .oqu"<;d t o te^KHid to .1 CO nW'< ^t-o/oc o<>ck<M NumixM v 1
C I AIMS ASni-i-:i) - PAR ] I
FOR
BASIC I
(37 CFR 1 l<5(a))
TOIALCITXIMS
(37 OT^ 1 1G(c))
(37 CFR 1 16(b)) ^
NUMGtRrU.tO
NUMBER EXHm
minus ?0 -
MUL
HPI.E rXilMlNlCNl CLAIM I'KI:SI:n1
(37 C\ y< 1 1<J(<1))
-„,.,od,lf..-.«n,:.MM.:.,U,nu,,i:;loss.l.mw«o..
CLAIMS AS AMIENOED - I^Al^T II
SMAll UN 111 Y
FEE
4
X i =
X 1 =
TOTAL
O lHI K 1HA!J
SMALL ENin Y
(Column 1)
(Column 2)
(Colunui 3)
CLAIMS
REMAINING
AFTER
AMCNDM£NT
HIGHEST
NUMBER
PREVIOUSLY
PAID FOR
PRESENT
EXTRA
Total
<37 CfR l.l<^<^))
/
(ndependent
(37Cr« VlC(b))
Minus
is
RRST PRESGt^
AKONO.: MULTIPLE OePE-«»^a.A.M (37 CFR 116(d))
(Cokjovi 1)
(Coluaui 2)
(C:o(umn 3)
CLAIMS
REMAINING
AFTER
AMENDMENT
HIGHEST
NUMBER
PREVIOUSLY
PA© FOR
PRESENT
EXTFA
Total
Minus
Independent
Minus
FIRST PRESEN
TAT.ON OF MULTIPI E QEPENDENT CLAiM (37 CFR 116(d))
iMALL ENTITY
OK
Ci-
Of-:
OR
RATE
X s
TOTAl
FEE
OTHER TIVaN
SMALL ENTH Y
r<AT£
ADDI
TtONAL
FEE
RATE
ADDL
TIONAL
FEE
X i
OR
X 5
OR
X s
+ S
OR
-t' $
TOTAL
ADO L FEE
OR
TOTAL
ADO L FEE
Total
<37 CFR 110(C))
Independent
p7 CfR t 16(b))
Mintis
(C olumn 2)
highest"
NUMBER
(Column 3)
PRESENT
EXTRA
FIRST PRESEKTATIONQFM.iLT.PLEOCPE«4«X3^CL/.M (37 CFR 1 16(d))
RATE
ADDI-
TIONAL
FEE
RATE
ADDI-
TIONAL
FEE
X $
OR
X $
X 5
OR
X i
+ i
OR
+ $
TOTAL
ADO L FEE
OR
TOTAL
ADO'LFEE
RATE
ADDI-
TIONAL
FEE
RATE
ADDI-
TIONAL
FEE
X J
OR
X V——
X J
OR
X i_ =
+ 1
OR
TOTAL
ADO L FEE
OR
TOTAL
ADOTFEE
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